Abortion

Key Features

Essentials of Diagnosis

• In the United States, > 60% of abortions are performed before 9 weeks, and > 90% are performed
before 13 weeks' gestation; only 1.3% are performed after 20 weeks

• If abortion is chosen, every effort should be made to encourage an early procedure

General Considerations

• The abortion-related maternal mortality rate has fallen markedly since the legalization of abortion in
the United States in 1973

• While several state laws limiting access to abortion and a federal law banning a rarely-used variation of
dilation and evacuation have been enacted, abortion remains legal and available until fetal viability
(between 24 and 28 weeks gestation) under Roe v. Wade

• The long-term sequelae of repeated induced abortions are uncertain regarding increased rates of fetal
loss or premature labor

• Adverse side effects can be reduced by performing abortion early with minimal cervical dilation or by
the use of osmotic dilators to induce gradual cervical dilation

Clinical Findings

Symptoms and Signs

• Pregnancy at less than the gestational age of viability

Diagnosis

Laboratory Tests

• Determine if patient is Rh positive or negative

• Pregnancy test

Diagnostic Procedures

• Establish date of last menstrual period (LMP) by pelvic examination or ultrasound

Treatment

Medications

• Mifepristone/misoprostol
• Day 1: Mifepristone (RU 486), 600 mg as a single dose; FDA-approved oral abortifacient

• Day 3: Misoprostol (a prostaglandin) 400 mcg orally in a single dose

• A more commonly used, evidence-based regimen is mifepristone, 200 mg orally on day 1, followed by
misoprostol, 800 mcg vaginally either immediately or within 6–8 hours

• Combination 95% successful in terminating pregnancies of up to 9 weeks' duration with minimum

complications

• Although not approved by the FDA for this indication, a combination of intramuscular methotrexate, 50
mg/m2 of body surface area, followed 3–7 days later by vaginal misoprostol, 800 mcg, is 98% successful
in terminating pregnancy at 8 weeks or less

• Minor side effects of nausea, vomiting, and diarrhea are common

• There is a 5–10% incidence of hemorrhage or incomplete abortion requiring curettage, but there are
no known long-term complications

Therapeutic Procedures

• Abortion in the first trimester is performed by vacuum aspiration under local anesthesia

• A similar technique, dilation and evacuation, is generally used in the second trimester, with general or
local anesthesia

• Techniques using intra-amniotic instillation of hypertonic saline solution or various prostaglandin

regimens, along with osmotic dilators, are also occasionally used after 18 weeks from the LMP but are
more difficult for the patient

Outcome

Complications

• Retained products of conception (often associated with infection and heavy bleeding)

• Unrecognized ectopic pregnancy; immediate analysis of the removed tissue for placenta can exclude or
corroborate the diagnosis of ectopic pregnancy

• Women with fever, bleeding, or abdominal pain after abortion should be examined; use of broad-
spectrum antibiotics and reaspiration of the uterus are frequently necessary

• Endometritis and toxic shock caused by Clostridium sordellii following medical abortion (rare)

Prognosis

• Legal abortion has a mortality rate of < 1:100,000

• Rates of morbidity and mortality rise with length of gestation

• Medical abortion is generally considered as safe as surgical abortion in the first trimester, but is
associated with more pain and a lower success rate (requiring surgical abortion)

• Overall, the risk of uterine infection is lower with medical than with surgical abortion

Prevention

• Contraception should be thoroughly discussed and provided at the time of abortion

• Prophylactic antibiotics are indicated; for instance

• A one-dose regimen of doxycycline, 200 mg orally 1 h before the procedure

• Many clinicians prescribe tetracycline, 500 mg four times daily orally, for 5 days after the procedure for
all patients as presumptive treatment for Chlamydia

• Rh immune globulin should be given to all Rh-negative women following abortion

When to Admit

• Hospitalization is advisable if acute salpingitis requires intravenous administration of antibiotics

• Complications following illegal abortion often need emergency care for hemorrhage, septic shock, or
uterine perforation

Reference

Guiahi M et al. First-trimester abortion in women with medical conditions: release date October 2012
SFP guideline #20122. Contraception. 2012 Dec;86(6):62230. [PMID: 23039921]